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Legal / Documentation Region VIII EMS Systems February, 2017 Objectives Review Region VIII SOPs for: ◦ POLST vs Living Will ◦ Power of Attorney for Healthcare ◦ Initiation of ALS Care Review Documentation Guidelines for: ◦ ◦ ◦ ◦ POLST / Withdrawal of Resuscitation Committals Healthcare Surrogates / Designated Decision Makers (DDMs) Narcotic Use and Disposition Review NEMSIS 3 and future of EMS data SME Video – Dr. Phillips http://tiny.cc/Feb17Vid POLST IL – The Facts POLST: ◦ Practitioner orders for Life Sustaining treatment ◦ Allows people with advanced illness to chose the type of treatment they would want ◦ Is intended for people of any age who are seriously ill or have life limiting illness The POLST form is an advance directive in accordance with Illinois law. It is NOT intended to replace a Power of Attorney for Health Care (POAHC) form, but to be used in addition to this form. (www.polstil.org) POLST Intended to be honored across various settings, including hospitals, nursing homes, and by emergency medical services personnel in the individual’s residence or in route to a healthcare facility Should be used to replace the previous IDPH form This provides individuals with choices regarding administration of CPR and other life sustaining treatments POLST This takes into account: ◦ The patient’s personal views ◦ The patient’s medical condition ◦ Patient views regarding CPR in the event of an unforeseen accident (car crash, chocking on food) ◦ Quality of life before and after CPR ◦ Patient view’s regarding use of CPR during surgery or other medical procedures ◦ Patient wishes for life sustaining treatments including mechanical ventilation, feeding tubes or other life sustaining treatments General POLST Guidelines If multiple forms are present, honor the one with the most recent date EMS is not responsible for investigating the presence of other forms ◦ Work with the form presented as being valid ◦ Verbal assurances of other existing forms can not be considered valid unless given by patient or legal guardian All copies of the form (original or duplicates) are valid Any color paper is valid POLST Sections 3Primary Medical Order Sections ◦ A. CPR If patient has no pulse or breathing ◦ B. Medical Interventions If patient is found with a pulse and/or is breathing ◦ C. Medically Administered Nutrition Requirements to make a POLST valid Patient Name Resuscitation Orders - Section A 3 Signatures ◦ Patient or Legal Representative ◦ Witness ◦ Practitioner (and name) Effective Date All other information is optional POLST / DNR Documentation Tips Narrative notes ◦ Time of death ◦ Physician name Details that bolster your assessment of the validity of the POLST form ◦ ◦ ◦ ◦ Effective date Who consented Name of Physician / APN / Medical Student / PA Witness info Completing the POLST Documentation of Discussion ◦ ◦ ◦ ◦ Patient Parent of Minor Agent under PoA Healthcare Surrogate (DM) Signature of Consent Signature of Witness Signature of Authorized Practitioner Illinois Health Care Surrogate Act When a patient lacks decisional capacity, the health care provider must make a reasonable inquiry as to the availability and authority of a health care agent under the Power of Attorney for Health Care Law. 2. If no Power of Attorney, the health care provider must make a reasonable inquiry as to the availability of possible surrogates (priority order on next slide). 3. The surrogate decision makers, as identified by the attending physician, are then authorized to make decisions for patients who lack decisional capacity. 1. Health Care Surrogate Priority Order (755 ILCS 40/25) 1. 2. 3. 4. 5. 6. 7. 8. Patient’s guardian of person Patient’s spouse or partner of a registered civil union Adult child Parent Adult sibling Adult grandchild A close friend of the patient The patient’s guardian of the estate Surrogate Decision Makers Cannot void an existing POLST or other Advanced Directive UNLESS THEY WERE THE SIGNEE WHO GAVE ORIGINAL CONSENT, or have subsequently been appointed as Power of Attorney, without identification / authorization by the patient’s attending physician. Would appear to be of limited use to EMS in an emergency situation where no advanced directive / POLST exists. Voiding / Revoking a POLST Form A patient with decisional capacity can void or revoke the form, and/or request alternative treatment. Changing / modifying / revising the form requires completion of a new form. Draw a line through sections A thru E and write “VOID” across the page of a revoked form. Beneath the written “VOID”, re-sign and write in the date. Voiding/Revoking a POLST Form Draw a line through sections A thru E and write “VOID” across the page of a revoked form. Beneath the written “Void”, resign and write in the date. What is the risk to EMS of using POLST? “A health care professional who in good faith complies with a do-not-resuscitate order made in accordance with this Act is not, as a result of that compliance, subject to any criminal or civil liability, except for willful and wanton misconduct, and may not be found to have committed an act of unprofessional conduct.” Illinois Health Care Surrogate Act Scenario 1 You are called to a local nursing facility for a possible DOA Patient is an 80 year old male, well known to your department Extensive history of chronic respiratory disease (COPD and heart failure) List of 13 medications Illinois POLST form, which appears to be properly executed Assessment GCS: 3 (E1,V1, M1) Skin: slightly cyanotic, cool, normal moisture Breathing: apneic Airway: open Circulation: pulseless Monitor: implanted pacemaker still firing, with wide QRS complexes What Do You Do? POLST clearly indicated patient’s intent to not have CPR Pacemaker generated PEA does not change the POLST Withhold CPR, contact Medical Control for pronouncement General Patient Assessment Emerging Infectious Diseases November 2016 ◦ MERS-CoV (Middle Ease Respiratory Syndrome Coronavirus) Saudi Arabia ◦ Human Infection with Avian Influenza A (H7N9) Virus China ◦ Dengue Fever Burkina Faso ◦ Rift Valley Fever Niger MERS Caused by coronavirus Symptoms include fever, cough and shortness of breath 3 to 4 out of 10 have died from the virus Can affect anyone form 1-99 years of age People with pre –existing medical conditions or weakened immune systems are more likely to be infected Incubation period is usually 5-6- days Influenza Composition of U.S. flu vaccines are reviewed annually and updated to match circulating flu viruses Current flu vaccine includes: ◦ A/California/7/2009 (H1N1)virus ◦ A/HongKong/4801/2014 (H3N2) virus ◦ B/Brisbane/60/2008 like virus Influenza A (H3 strain) is the predominate strain being seen currently Adult Initial Medical Care - Reminders Per Region VIII SOPs ◦ Target SpO2 for most patients is 94-98% - administer oxygen to achieve that target ◦ Continued use of existing central venous access devices is acceptable if initiated by RN or physician – document identity of person who initiated care, contact Medical Control before giving any medications via that access ◦ Pain and nausea management should be considered for all patients Adult Initial Medical Care - Reminders Time Sensitive Patients – Attempt to contact Medical Control as soon as possible This is to allow destinations as much time as possible to prepare/ alert staff for your arrival If you or the patient desire transport to other than the closest facility: ◦ You must contact Medical Control BEFORE beginning transport ◦ Medical Control must verify the availability of the receiving hospital before authorizing the bypass Documentation Tips about AIMC Just making a narrative note of “IMC” is inadequate. Document : ◦ initial patient presentation, ◦ interventions ◦ reassessment after each intervention Baseline physical exam and reassessment Baseline vital signs and reassessment Only document blood glucose if done Baseline (room air) SpO2, plus SpO2 with FiO2 if oxygen given Per SOP, are you allowed to discontinue cardiac monitoring? Adult Initial Medical Care ◦ “All ALS patients do not necessarily require continuous ECG monitoring…” Initiation of ALS Care ◦ “Never discontinue ALS once initiated unless prior approval by Medical Control” “What if…” – for group discussion Radio Call Radio Report TRANSMIT THE FOLLOWING, BEING AS CONCISE AS POSSIBLE: 1. Name and vehicle number of provider, desired destination, and ETA. Indicate if desired destination is the nearest by travel time, and any reasons for desiring to transport to other than the nearest hospital. 2. Patient age, sex, and approximate weight. 3. Level of consciousness and orientation. 4. Chief complaint and paramedic impression, including severity: symptoms, degree of distress, severity of pain on a scale of 0-10 mechanism of trauma/pertinent scene information pertinent negatives/associated complaints 5. Signs GCS Pulse - rate, quality, regularity Blood Pressure - auscultated or palpated Respirations - rate, pattern, depth Skin - color, temperature, moisture, turgor Pupils – size, equality, reactivity Lung Sounds Radio Report 6. History • Signs and Symptoms • Allergies • Medications: time and last dosage taken (bring all medications to ED) • Past history of pertinent illness/injury • Last oral intake (food or fluid) if known, Last Menstrual Period • Events surrounding event 7. Clinical findings • Assessment findings from review of systems pertinent (+) and (-) findings • Interpretation of ECG and vital signs • Blood glucose for patients with altered mental status • Body temperature when appropriate • Cincinnati Prehospital Stroke Scale when appropriate • Trauma score parameters if appropriate How would you call this in? EMS Documentation With every PCR you write ◦ Imagine it enlarged on the big screen for judge and jury? ◦ How is your spelling? ◦ How organized are your thoughts? ◦ Did you use creative or not approved abbreviations? Documentation To a layperson on a jury, a PCR that may be fully completed and accurate may still seem unreliable or even incomplete if it is sloppy, full of misspellings, or disorganized. Documentation Documentation can be used to call into question your competence as a ◦ Provider ◦ Your ability to render care ◦ Your skills Documentation Keep these concepts in mind when writing your report: ◦ Make sure your spelling is correct or utilize spellcheck ◦ If you are in doubt look it up or change a word ◦ Use only approved recognizable medical abbreviations, otherwise spell it out! ◦ Double check the accuracy of patient’s name, DOB, and other identifiers. If not sure document why! ◦ Double check each box to make sure everything is covered Documentation If something is missing part of an assessment may be overlooked Note times of any significant change in patient’s condition When pain started? When injury occurred? Identify and attribute statements made by others that pertinent to the call Documentation Be an Artist and Paint the picture Organize your narrative so the reader get a sequential picture of the call from beginning to end Do not rely on check boxes to tell the story Every person who sees your PCR should know what you did and when you did it Power of Attorney for Health Care Does not require an attorney or physician to execute Allows the appointed person to speak on the patient’s behalf in decisions of health care If multiple PoA documents are executed, the one with the most recent date supercedes all previous Power of Attorney for Health Care Powers: ◦ ◦ ◦ ◦ ◦ ◦ Talk to physicians and other health care providers about patient’s condition See medical records and approve who else can see them Give permission for tests, medicines, surgery, other treatments Choose where the patient receives care Choose who the patient receives care from Decide to accept, withdraw or decline treatments “designed to keep you alive if you are near death or not likely to recover” ◦ Agree or decline organ donation ◦ Decide what happens to your remains after you have died, if not otherwise specified ◦ Consult with your other loved ones to help come to a decision (but the Agent has final say) Executing Power of Attorney Patient name and address Designated agent name, address and phone # Enumerated powers PoA Signatures Successor Agents In the event that the primary Agent cannot be contacted or does not wish to act during a time of need, successor agents (if specified, in the order listed) are asked to act Only one agent at a time can act May be more than two successors (add another page) EMS interaction with PoA / Surrogates In the absence of a POLST / DNR, Region VIII SOPs do not allow EMS to honor decisions or expressions by PoA or Surrogates in the arrest situation No PoA? Living Will On the Power of Attorney form (IDPH) WHAT IF THERE IS NO ONE AVAILABLE WHO I TRUST TO BE MY AGENT? In this situation, it is especially important to talk to your physician and other health care providers and create written guidance about what you want or do not want, in case you are ever critically ill and cannot express your own wishes. You can complete a living will… Living Wills Not applicable to prehospital emergency care unless accompanied by a properly executed POLST / DNR If arrest situation and family (not designated as PoA or guardian) wants to withhold or withdraw resuscitation, begin and contact Medical Control; follow orders received Patients registered in hospice are almost certain to have advanced directives (Living Will, POLST / DNR) Follow Section A (CPR) and B (Medical Interventions) of POLST Documentation Tips – non-POLST Thoroughly document all interactions with family members / surrogates / PoAHC, and all Medical Control interactions If Living Will with no POLST, be sure to document any actions you took to attempt to locate POLST form Involuntary Admission This discussion assumes you have met the threshold for transporting the patient ◦ The patient willingly goes with EMS ◦ The patient is placed into protective custody by law enforcement and EMS is transporting ◦ The patient has been ordered admitted by a court order and law enforcement / EMS collaborate to facilitate the admission Illinois Admission Petition If you are asked to enter information in a petition, you are only entering what you saw or heard, similar to what you would write in your PCR You are participating in a request by the hospital, social services or crisis workers to allow the patient to be admitted for 24 hours for psychiatric evaluation Documentation Tips – Involuntary Admissions Be sure to write the same findings in your narrative that you write on the petition, to eliminate any perception of a conflict Use of patient quotations is best, as well as directly quoting bystander statements Objective observations only The Ideal Data World Medication of the Month Atropine Atropine Indications ◦ Symptomatic bradycardia ◦ Muscarinic / organophosphate poisoning ◦ Has not been recommended for use in cardiac arrest since the 2012 SOP revision Cardiovascular / Physiologic Effects Atropine is an indirect cardioaccelerator Parasympathetic NS is always “dragging the brake” Atropine blocks the parasympathetic NS / blocks the brake pedal Inhibits the CNS from slowing the heart rate Organophosphate Effects Primary mechanism of action of organophosphate pesticides is inhibition of acetylcholinesterase (AChE) ◦ AChE helps break down Ach for use in the CNS ◦ When AChE is inhibited, Ach accumulates throughout the nervous system, resulting in overstimulation of muscarinic and nicotinic receptors, which causes the symptoms Organophospate Patient Presentation Muscarinic ◦ SLUDGEBAM Nicotinic ◦ ◦ ◦ ◦ Muscle fasciculations Cramping Weakness HTN / tachycardia CNS ◦ ◦ ◦ ◦ ◦ Anxiety Mental status / mood changes Tremors Seizure Coma Vitals Depressed respirations Bradycardia Hypotension Tachypnea Hypertension Tachycardia Continuous pulse oximetry Vitals can be stimulated or depressed Atropine Documentation Tips – Controlled Substances Controlled substance storage / security ◦ System / Agency specific documentation procedure Original (now broken) tag number if tags used New (unbroken) tag number What is your procedure for documenting dosages given, dosages wasted, disposition? Scenario 3 You are called to the single family residence for a man who “passed out” Now reported to be conscious and breathing What is important to include in your radio report?? The Rest of the Story The patient was eating breakfast when “he went face down in his corn flakes” ( per family member) Patient is a 47 year old male Family member doesn’t know patient’s medical history Current GCS 12 (E3, V4, M5) Unable to clearly elicit history, meds, allergies because patient is disoriented Physical Exam Skin unremarkable (normal x3) Breathing – normal 14/minute Airway – Open Circulation – pulse 68, strong and slightly irregular Lungs clear Eyes PERL 5mm Blood Sugar 109 Cardiac Rhythm Sinus Arrest versus Sinus Block? Transport or Not Patient repeat GCS =15 Wants to refuse care Do you let him sign a refusal? Call Medical Control? Outcome This is a real life scenario The crew convinced the patient to be transported for evaluation ◦ “you don’t know why you passed out, and neither do we” IMC, monitor On arrival at the hospital, patient suffered extended sinus arrest (> 10 seconds) and was immediately put on standby transcutaneous pacing, taken to the cath lab for an implantable pacemaker insertion ECG Rhythm of the Month Sinus Arrest / Block generically sinus node dysfunction Sinus Node Dysfunction Sinus node is usually reliable and regular SND is diagnosed when sinus node fails to properly generate and/or propagate impulses Mild dysfunction usually produces no symptoms As dysfunction increases, symptoms may include signs/symptoms of hypoperfusion and/or sensation of irregular heartbeat 1:600 cardiac patients > 65 years old Etiology Intrinsic causes ◦ Age-related sinus node changes ◦ Coronary Artery Disease Atherosclerotic changes in sinus node artery Extrinsic causes ◦ Medications Digitalis, propranolol, verapamil, quinidine, procainamide, lidocaine, reserpine ◦ Autonomic nervous system hyperactivity Sinus Block Sinus Block With SA block, the R-R interval for the gap: ◦ Is usually short (only one missing beat) ◦ Resumes cadence within ~ .08 sec (2 small boxes) Sinus Arrest With SA arrest, the R-R interval for the gap: ◦ May be short or long (> 1 missing beat, pause can be several seconds duration) ◦ Does not usually resume previous cadence Signs & Symptoms One missing beat ◦ Patient feels palpitation or irregularity ◦ Usually no cardiovascular implications Multiple missing beats, long pauses ◦ May be decrease in cardiac output ◦ Escape beat may be sensibly different than other heartbeats if different pacemaker site Question – what do you call a sinus arrest that does not resume normal beats?
